Transnasal Esophagoscopy: Our Future is here, and the time is now.

This week SDX is continuing to feature articles created by current SLPs. This week we feature “Transnasal Escophagoscopy: Our Future is here, and the time is now” by Shawneen Buckley.

Shawneen Buckley has been working as an SLP for 24 years throughout the Northeast, in a variety of clinical and leadership positions across the healthcare continuum. She currently works in a SNF with a robust subacute unit, and is an Adjunct Faculty member at Southern Connecticut State University, serving as the Advanced Clinical Practicum Coordinator. Please enjoy her article which begins below.

In the past 20 years, instrumental swallowing assessment has evolved significantly, with FEES now being fully portable, and commonplace in nearly all medical settings across the country. Today, SLP’s are confidently and competently performing FEES every day. We, as SLP’s, have been taught to evaluate as far as the UES and no farther but…  hold onto your scopes because things are about to get even more interesting- TransNasal Esophagoscopy (TNE) is coming to an SLP near you!

I recently attended a course entitled “Acid Reflux Disease- Office Diagnostics to Food is Medicine: What the SLP Should Know.” by Dr. Jonathan Aviv, MD. FACS, ENT, who suggested that the SLP is the right professional to perform TNE in the near future. He expects that there will be an increased demand for TNE due to the growing problem of Acid Reflux Disease, and the benefits of TNE over EGD including; fewer medical complications, lower cost, and equal quality. 

What is Acid Reflux Disease? Gastroesophageal Reflux Disease (GERD) is the backflow of gastric material to the esophagus. Laryngopharyngo Reflux (LPR)is backflow of gastric contents through the esophagus and  up to the level of the throat. LPR can cause tissue damage throughout the pharynx and larynx causing edema, dysphagia, vocal fold dysfunction, and granuloma to name a few. Left untreated, Acid Reflux Disease may result in Barrett Esophagus, which, in turn, may predispose patients to a higher risk of cancer.  Esophageal-Adeno Carcinoma is the fastest growing cancer in the US and Europe, with 7 times greater occurrence today that a mere 30 years ago. Currently, 20% of the US population has acid reflux- that is a whopping 60 million people!!

 

Why is GERD and Esophageal Adeno cancer on the rise? According to Johnathan Aviv, MD, our eating and drinking habits are the cause- the acidic nature of what we ingest damages the throat on the way down, as well as on the way back up. Myriad changes to what and how we eat and drink over that past 30 + years has increased the occurrence of acid reflux, including:

  • A cultural shift from cooking from scratch to ingesting processed and packaged foods.
  • Movement by the government to acidify food to prevent botulism.
  • Increased popularity of sugar soda, made with high fructose corn syrup which is processed with sulfuric acid and contains a chemical that loosens the LES.
  • Commonplace use of preservatives in foods which loosens the LES.
What should every SLP know? Acid Reflux affects both genders, and occurs at any age. Symptoms of Esophageal Adeno Carcinoma includes symptoms that are all to familiar to SLP’s, including: dysphagia, hoarseness, chronic cough, frequent throat clearing, and globus. Early identification is crucial, and SLP’s should not hesitate to make referrals. TNE is a very good physiologic evaluation of the esophagus and can play an important part in early identification.  
Who should you refer your patients to? Put very simply: when your patient reports heart burn, refer to a GI doctor When they report throat burn, refer to an ENT doctor.

What  exactly is TNE? TNE is an instrumental assessment of the esophageal anatomy, physiology and function. It is performed without sedation (unlike EGD) and can be done in an office setting. The nasendoscope is passed through nasal passages, to the pharynx, at which time, the patient burps or swallows some water allowing the scope to be passed through the UES, into the cervical esophagus. While in the esophagus, the tissue and function of the esophagus is observed. The scope is then passed on through the LES and into the stomach. The scope can then view the stomach tissue, and LES from the within the stomach, looking up!

Why is TNE a natural evolution for the SLP? 

In a nutshell, the TNE is an extension of the FEES. We are already passing the scope, experts in the anatomy, physiology, and function of the oropharynx/larynx, and often the first professional to objectively describe symptoms of esophageal dysphagia as observed during the FEES, MBS or clinical swallowing evaluation. The next logical step is for our profession to assess the esophageal phase of swallow by performing TNE. Additionally, Dr. Aviv indicated that millions of people are going to need TNE and there simply are not going to be enough ENT’s or GI doctors to respond to that need.  
When is TNE indicated? When symptoms of acid reflux include; pharyngeal symptoms (coughing, hoarsness), dysphagia, differential diagnosis, long standing GERD, monitoring Barretts patients, evalutating patient with abnormal barium swallow findings.
Where does ASHA stand on SLP’s performing TNE? In an ASHA clinical practice paper written in 2008, TNE was identified as an emerging area for SLP’s. ASHA lists esophageal dysphagia as a service delivery area but has no specific policies yet.
What can you do right now about the acid reflux epidemic? Here are six foods to avoid and advise your patients to avoid:
Sugar soda
Bottled Iced Tea
Tomato
Vinegar
Wine
Lemon/Citrus fruits.

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